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Summary Benchmarks for Preferred Practice Pattern® Guidelines

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Summary Benchmarks for Preferred Practice Pattern® Guidelines SUMMARY BENCHMARKS FOR PREFERRED PRACTICE PATTERN® GUIDELINES TABLE OF CONTENTS Summary Benchmarks for Preferred Practice Pattern Guidelines Introduction . 1 Glaucoma Primary Open-Angle Glaucoma (Initial Evaluation) . 3 Primary Open-Angle Glaucoma (Follow-up Evaluation) . 4 Primary Open-Angle Glaucoma Suspect (Initial and Follow-up Evaluation) . 5 Primary Angle Closure (Initial Evaluation and Therapy) . 6 Retina Age-Related Macular Degeneration (Initial and Follow-up Evaluation) . 7 Age-Related Macular Degeneration (Management Recommendations) . 8 Diabetic Retinopathy (Initial and Follow-up Evaluation) . 9 Diabetic Retinopathy (Management Recommendations) . 10 Idiopathic Epiretinal Membrane and Vitreomacular Traction (Initial Evaluation and Therapy) . 11 Idiopathic Macular Hole (Initial Evaluation and Therapy) . 12 Posterior Vitreous Detachment, Retinal Breaks, and Lattice Degeneration (Initial and Follow-up Evaluation) . 14 Retinal and Ophthalmic Artery Occlusions (Initial Evaluation and Therapy) . 15 Retinal Vein Occlusions (Initial Evaluation and Therapy) . 16 Cataract/Anterior Segment Cataract (Initial and Follow-up Evaluation) . 17 Cornea/External Disease Bacterial Keratitis (Initial Evaluation) . 19 Bacterial Keratitis (Management Recommendations) . 20 Blepharitis (Initial and Follow-up Evaluation) . 21 Conjunctivitis (Initial Evaluation) . 22 Conjunctivitis (Management Recommendations) . 23 Corneal Ectasia (Initial Evaluation and Follow-up) . 24 Corneal Edema and Opacification (Initial Evaluation) . 25 Corneal Edema and Opacification (Management Recommendations) . 26 Dry Eye Syndrome (Initial Evaluation) . 27 Dry Eye Syndrome (Management Recommendations) . 28 Pediatric Ophthalmology/Strabismus Amblyopia (Initial and Follow-up Evaluation) . 29 Esotropia (Initial and Follow-up Evaluation) . 30 Exotropia (Initial and Follow-up Evaluation) . 31 Refractive Management/Intervention Keratorefractive Surgery (Initial and Follow-up Evaluation) . 32 Adult Strabismus Adult Strabismus with a History of Childhood Strabismus . 33 © 2019 American Academy of Ophthalmology October 2019 aao org. SUMMARY BENCHMARKS FOR PREFERRED PRACTICE PATTERN® GUIDELINES Introduction Cochrane Library for articles in the English language These are summary benchmarks for the Academy’s is conducted . The results are reviewed by an expert Preferred Practice Pattern® (PPP) guidelines . The panel and used to prepare the recommendations, Preferred Practice Pattern series of guidelines has which are then given a rating that shows the strength been written on the basis of three principles . of evidence when sufficient evidence exists . • Each Preferred Practice Pattern should be clinically To rate individual studies, a scale based on the relevant and specific enough to provide useful Scottish Intercollegiate Guideline Network (SIGN) is information to practitioners . used . The definitions and levels of evidence to rate • Each recommendation that is made should be given individual studies are as follows: an explicit rating that shows its importance to the • I++: High-quality meta-analyses, systematic reviews care process . of randomized controlled trials (RCTs), or RCTs with • Each recommendation should also be given an a very low risk of bias explicit rating that shows the strength of evidence • I+: Well-conducted meta-analyses, systematic that supports the recommendation and reflects the reviews of RCTs, or RCTs with a low risk of bias best evidence available . • I–: Meta-analyses, systematic reviews of RCTs, or Preferred Practice Patterns provide guidance RCTs with a high risk of bias for the pattern of practice, not for the care of a • II++: High-quality systematic reviews of case-control particular individual. While they should generally or cohort studies; high-quality case-control or meet the needs of most patients, they cannot possibly cohort studies with a very low risk of confounding best meet the needs of all patients . Adherence to or bias and a high probability that the relationship is these Preferred Practice Patterns will not ensure a causal successful outcome in every situation . These practice • II+: Well-conducted case-control or cohort studies patterns should not be deemed inclusive of all proper with a low risk of confounding or bias and a methods of care or exclusive of other methods of moderate probability that the relationship is causal care reasonably directed at obtaining the best results . It may be necessary to approach different patients’ • II–: Case-control or cohort studies with a high risk of needs in different ways . The physician must make the confounding or bias and a significant risk that the ultimate judgment about the propriety of the care of relationship is not causal a particular patient in light of all of the circumstances • III: Nonanalytic studies (e g. ., case reports, case presented by that patient . The American Academy series) of Ophthalmology is available to assist members in resolving ethical dilemmas that arise in the course of Recommendations for care are formed based on the ophthalmic practice . body of the evidence . The body of evidence quality ratings are defined by Grading of Recommendations The Preferred Practice Pattern® guidelines are not Assessment, Development and Evaluation (GRADE) medical standards to be adhered to in all individual as follows: situations. The Academy specifically disclaims any • Good quality (GQ): Further research is very unlikely and all liability for injury or other damages of any kind, to change our confidence in the estimate of effect from negligence or otherwise, for any and all claims that may arise out of the use of any recommendations • Moderate quality (MQ): Further research is likely to or other information contained herein . have an important impact on our confidence in the estimate of effect and may change the estimate For each major disease condition, recommendations • Insufficient quality (IQ): Further research is for the process of care, including the history, physical very likely to have an important impact on our exam and ancillary tests, are summarized, along with confidence in the estimate of effect and is likely to major recommendations for the care management, change the estimate; any estimate of effect is very follow-up, and education of the patient . For each uncertain PPP, a detailed literature search of PubMed and the © 2019 American Academy of Ophthalmology October 2019 aao org. 1 SUMMARY BENCHMARKS FOR PREFERRED PRACTICE PATTERN® GUIDELINES Introduction (continued) • Level I includes evidence obtained from at least Key recommendations for care are defined by GRADE one properly conducted, well-designed randomized as follows: controlled trial . It could include meta-analyses of randomized controlled trials . • Strong recommendation (SR): Used when the desirable effects of an intervention clearly outweigh • Level II includes evidence obtained from the following: the undesirable effects or clearly do not • Well-designed controlled trials without • Discretionary recommendation (DR): Used when the randomization trade-offs are less certain—either because of low- • Well-designed cohort or case-control analytic quality evidence or because evidence suggests studies, preferably from more than one center that desirable and undesirable effects are closely • Multiple-time series with or without the balanced intervention In PPPs prior to 2011, the panel rated recommendations • Level III includes evidence obtained from one of the according to its importance to the care process . This following: “importance to the care process” rating represents • Descriptive studies care that the panel thought would improve the quality • Case reports of the patient’s care in a meaningful way . The ratings • Reports of expert committees/organizations (e g. ., of importance are divided into three levels . PPP panel consensus with external peer review) • Level A, defined as most important • Level B, defined as moderately important This former approach, however, will eventually be • Level C, defined as relevant but not critical phased out as the AAO adopted the SIGN and GRADE rating and grading systems . The panel also rated each recommendation on the strength of evidence in the available literature to The PPPs are intended to serve as guides in patient support the recommendation made . The “ratings of care, with greatest emphasis on technical aspects . In strength of evidence” also are divided into three levels . applying this knowledge, it is essential to recognize that true medical excellence is achieved only when skills are applied in a such a manner that the patients’ needs are the foremost consideration . The AAO is available to assist members in resolving ethical dilemmas that arise in the course of practice . (AAO Code of Ethics) © 2019 American Academy of Ophthalmology October 2019 aao org. 2 GLAUCOMA Primary Open-Angle Glaucoma (Initial Evaluation) Initial Exam History (Key elements) • Laser trabeculoplasty can be considered as initial • Ocular history therapy in selected patients or an alternative for • Race/ethnicity patients at high risk for nonadherence to medical therapy who cannot or will not use medications • Family history reliably due to cost, memory problems, difficulty • Systemic history with instillation, or intolerance to medication (I+, GQ, • Review of pertinent records DR) • Current medications • Trabeculectomy is effective in lowering IOP; it is gen- • Ocular surgery erally indicated when medications and appropriate laser therapy are insufficient to control disease
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